Provider Demographics
NPI:1609251115
Name:JOHNSON, KELSEY JOY-MARIE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:JOY-MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3903
Mailing Address - Country:US
Mailing Address - Phone:740-687-0042
Mailing Address - Fax:
Practice Address - Street 1:624 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130
Practice Address - Country:US
Practice Address - Phone:740-687-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-26
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1800795101YP2500X
OHE2722-S101YP2500X
OHE.1800795-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional